PRELIMINARY KNKT.11.08.14.04

NN AATTIIOONNAALL TT RRAANNSSPPOORRTTAATTIIOONN

SSAAFFEETTYY

CCOOMMMMIITTTTEEEE

Aircraft Accident Investigation Report

PT. Nyaman Air Service Bell 412; PK–FUG Dua Saudara Mountain, , North Republic of

3 August 2011

NATIONAL TRANSPORTATION SAFETY COMMITTEE MINISTRY OF TRANSPORTATION

REPUBLIC OF INDONESIA 2011

This Preliminary Report was produced by the National Transportation Safety Committee (NTSC), Ministry of Transportation 3rd Floor, Jalan Medan Merdeka Timur No. 5 10110, Indonesia. The report is based upon the initial investigation carried out by the NTSC in accordance with Annex 13 to the Convention on International Civil Aviation Organization, the Indonesian Aviation Act (UU No. 1/2009) and Government Regulation (PP No. 3/2001). Readers are advised that the NTSC investigates for the sole purpose of enhancing aviation safety. Consequently, the NTSC reports are confined to matters of safety significance and may be misleading if used for any other purpose.

As the NTSC believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging the NTSC as the source.

When the NTSC makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the NTSC fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in NTSC reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability.

TABLE OF CONTENTS

TABLE OF CONTENTS ...... i TABLE OF FIGURES ...... iii GLOSSARY OF ABBREVIATIONS ...... iv INTRODUCTION ...... 1 1 FACTUAL INFORMATION ...... 2 1.1 History of the Flight...... 2 1.2 Injuries to Persons...... 3 1.3 Damage to Aircraft ...... 3 1.4 Other Damage ...... 4 1.5 Personnel Information ...... 4 1.5.1 Pilot in command ...... 4 1.5.2 Maintenance Engineer ...... 5 1.6 Aircraft Information ...... 5 1.6.1 General ...... 5 1.6.2 Engines ...... 5 1.6.3 Main rotor blade ...... 6 1.6.4 Weight and Balance ...... 6 1.7 Meteorological Information ...... 6 1.8 Aids to Navigation ...... 7 1.9 Communications ...... 7 1.10 Aerodrome Information ...... 7 1.11 Flight Recorders ...... 7 1.12 Wreckage and Impact Information ...... 7 1.13 Medical and Pathological Information ...... 7 1.14 Fire ...... 7 1.15 Survival Aspects ...... 7 1.16 Tests and Research ...... 8 1.17 Organizational and Management Information ...... 8 1.18 Additional Information ...... 8 1.18.1 Visual flight track ...... 8 1.19 Useful or Effective Investigation Techniques ...... 10

i 2 ANALYSIS ...... 11 3 CONCLUSIONS ...... 12 4 SAFETY ACTION ...... 13 5 SAFETY RECOMMENDATIONS ...... 14 5.1 Recommendation to PT. PT Nyaman Air ...... 14 5.2 Recommendation to Directorate General of Civil Aviation ...... 14

ii TABLE OF FIGURES

Figure 1: The Bell 412 helicopter registrasi PK-FUG accident location ...... 3 Figure 2: The Bell 412 Helicopter condition after accident ...... 4 Figure 3: VFR route within CTR /TMA ...... 9 Figure 4: The aircraft PK-FUG accident route ...... 9

iii GLOSSARY OF ABBREVIATIONS

AD Airworthiness Directive AFM Airplane Flight Manual ALAR Approach-and-landing Accident Reduction AOC Air Operator Certificate ATC Air Traffic Control ATPL Air Transport Pilot License ATS Air Traffic Service BMKG Badan Meterologi Klimatology dan Geofisika CASO Civil Aviation Safety Officer CASR Civil Aviation Safety Regulation CPL Commercial Pilot License COM Company Operation Manual CRM Cockpit Recourses Management CSN Cycles Since New CVR Cockpit Voice Recorder DGCA Directorate General of Civil Aviation EFIS Electronic Flight Instrument System FL Flight Level FDR Flight Data Recorder ICAO International Civil Aviation Organization IFR Instrument Flight Rules IIC Investigator in Charge ILS Instrument Landing System Kg Kilogram(s) Km Kilometer(s) Kts Knots (NM/hour) Mm Millimeter(s) MTOW Maximum Take-off Weight NM Nautical mile(s) KNKT / NTSC Komite Nasional Keselamatan Transportasi National Transportation Safety Committee °C Degrees Celsius PIC Pilot in Command QFE Height above aerodrome elevation (or runway threshold elevation) based on local station pressure QNH Altitude above mean sea level based on local station pressure

iv SCT Scattered S/N Serial Number TSN Time Since New TT/TD Ambient Temperature/Dew Point UTC Coordinated Universal Time VFR Visual Flight Rules VMC Visual Meteorological Conditions

v

INTRODUCTION

SYNOPSIS

On 3 August 2011, a Bell 412 helicopter, registered as PK-FUG, was being operated by PT. Nyaman Air. The helicopter was in an unscheduled chartered flight mission by PT Nusa Halmahera Mineral (NHM).

At the day of accident, the helicopter was conducting flight route Gosowong – Manado – Gosowong. After landed at Sam Ratulangi Airport, Manado (MDC/WAMM)1, , the aircraft dispatched to continue flight to Gosowong.

The aircraft took-off from Manado at 0626 UTC2 (14:26 LT) and it was operated by single pilot. The people on board were 10 persons, consist of one pilot, one engineer and eight passengers.

Based on the last communication with Manado ATC at 0629 UTC, the aircraft position was on radial 105 from MNO VOR at 4.5 NM.

About 30 minutes after last communication, the Manado approach declare alert phase. About 32 minutes after las communication declare ALERFA.

After the Manado approach declare ALERFA, about 61 minutes, they declare DESTRESFA.

About 28 minutes after their declare DESTRESFA, their received information from Skynet Balikpapan the last position of the aircraft. The aircraft location at coordinate N 01º 28’ 51.90” E 125º 08’ 19.21” as Dua Saudara mountain and elevation 2,308 feet.

Upon receiving distress notification from the Airport Authority, National Search and Rescue Agency (BASARNAS) deployed a team and discovered the aircraft wreckage.

The aircraft suffered substantial damage and all passengers and crew fatally injured.

At the time of issuing this Preliminary Aircraft Accident Investigation Report, the investigation is proceeding.

1 Sam Ratulangi Airport will named Manado for the purposes of this report.

2 The 24-hours clock used in this report to describe the time of day as specific events occured, is in Coordinated Universal Time (UTC). Local Time, Centre Indonesian Standard Time (WITA) is UTC+8 hours.

1 1 FACTUAL INFORMATION 1.1 History of the Flight

On 3 August 2011, a Bell 412 helicopter, registered as PK-FUG, was being operated by PT. Nyaman Air. The helicopter was in an unscheduled chartered flight mission by PT Nusa Halmahera Mineral (NHM).

At the day of accident, the helicopter was conducting flight route Gosowong – Manado – Gosowong. After landed at Sam Ratulangi Airport, Manado (MDC/WAMM)3, North Sulawesi, the aircraft dispatched to continue flight to Gosowong.

The aircraft took-off from Manado at 0626 UTC4 (14:26 LT) and it was operated by single pilot. The people on board were 10 persons, consist of one pilot, one engineer and eight passengers.

Based on the last communication with Manado ATC at 0629 UTC, the aircraft position was on radial 105 from MNO VOR at 4.5 NM.

At 0646 UTC the Manado ATC contacted the aircraft, however, there was no answer.

At 0647 UTC, the Manado Approach seeking information in the Manado information office, tower and station PT Nyaman Air about the aircraft.

At 0659 UTC The Manado approach declare alert phase and informed the brieifng office. At 0701 UTC The briefing office declared ALERFA5 to other related ATS. At 0802 the briefing office declared DESTRESFA6 to the other related ATS.

About 0830 UTC the Manado Approach received information from Skynet Balikpapan the last position of the aircraft. The aircraft location at coordinate N 01º 28’ 51.90” E 125º 08’ 19.21” as Dua Saudara mountain and elevation 2,308 feet.

Upon receiving distress notification from the Airport Authority, National Search and Rescue Agency (BASARNAS) deployed a team.

At 1650 UTC the BASARNAS discovered the aircraft wreckage.

3 Sam Ratulangi Airport will named Manado for the purposes of this report.

4 The 24-hours clock used in this report to describe the time of day as specific events occured, is in Coordinated Universal Time (UTC). Local Time, Centre Indonesian Standard Time (WITA) is UTC+8 hours.

5 ALERFA : alert phase when there is apprehension about the safety of an aircraft and its occupants when communication is not received or the aircraft fails to arrive within 60 minutes of a prescribed time.

6 DETRESFA: Distress phase when there is reasonable certainty that the aircraft and its occupants are threatened by grave and imminent danger.

2 The aircraft suffered substantial damage and all passengers and crew fatally injured.

satelite photograph courtessy of google earth

Figure 1: The Bell 412 helicopter registrasi PK-FUG accident location

1.2 Injuries to Persons

Injuries Flight crew Passengers Total in Aircraft Fatal 1 9 10 Serious - - - Minor - - - Nil Injury - - - TOTAL 1 9 10

Two passenger on board was and two passenger on board was South African.

1.3 Damage to Aircraft

The aircraft destroy.

3

Figure 2: The Bell 412 Helicopter condition after accident

1.4 Other Damage

There was no other damage to property.

1.5 Personnel Information

1.5.1 Pilot in command

Gender : Male Date of birth : 07 September 1955 Nationality : Indonesia License : ATPL/H Date of issue : 13 April 2011 Valid to : 30 April 2012 Aircraft type rating : Bell 212; Bell 412, Bell 205, Bell 206 ,BO-105 Medical certificate : Class I Date of medical : 12 July 2011 Valid to : 12 January 2012 Last proficiency check : 08 February 2011 Total hours : 11,907 hours 18 minutes This make and model : 1,998 hours 42 minutes Last 90 days : 70 hours 12 minutes Last 24 hours : 2 hours 24 minutes This flight : about 1 hour 34 minutes

4 1.5.2 Maintenance Engineer

Gender : Male Date of birth : 12 October 1969 Nationality : Indonesia License : AMEL Aircraft type rating : Bell 212,Bell 412, Bell 206 PW PT6T-series

1.6 Aircraft Information 1.6.1 General

Aircraft Registration : PK-FUG Country of Manufacturer : United State of America Manufacturer : Bell Helicopter Textron Type/ Model : Bell 412 HP Serial Number : 36063 Year of Manufacture : 1993 Certificate of Airworthiness validity : 27 January 2012 Certificate of Registration : 27 January 2012 Total flying hours since manufacture : To be affirmend by Operator Total cycle since new : 16,769 cycles

1.6.2 Engines

Engine type : Turbo Shaft Manufacturer : Pratt Whitney Model : PT6T- 3BE Engine #1 Serial Number : CP-PS-T13O174 Time Since New (TSN) : 2,250 hours Cycle since new Engine : 4,835 cycles Engine #2 Serial Number : CP-PS-T13O175

5 Time Since New (TSN) : 2,250 hours Cycle since new : 4,835 cycles

1.6.3 Main rotor blade

MR type : Composite Bell Textron Blade #1 Serial number : A-1660 Time Since New : 1,867 hours 48 minutes Time between Overhaul : 2,500 hours Blade #2 Serial number : A-1663 Time Since New : 1,867 hours 48 minutes Time between Overhaul : 2,500 hours Blade #3 Serial number : A-1654 Time Since New : 1,867 hours 48 minutes Time between Overhaul : 2,500 hours Blade #4 Serial number : A-1668 Time Since New : 1,867 hours 48 minutes Time between Overhaul : 2,500 hours

1.6.4 Weight and Balance

The pilot did not make a weight and balance calculation prior the accident.

1.7 Meteorological Information

Surface wind : 330º/ 8 knot Visibility : 10 Km Weather : NIL Cloud base : F 2100 feet Bkn 10000 feet TT / TD : 29° C / 22° C QNH : 1008 mb / 29.77 QFE : 1000 mb / 29.49

6 1.8 Aids to Navigation

Not relevant to this accident.

1.9 Communications

Communications between air traffic services (ATS) and the crew was normal and no communication difficulty. Last contact communication held at 0629 UTC.

1.10 Aerodrome Information

Airport Name : Sam Ratulangi Airport Airport Identification : WAMM / MDC Elevation : 270 feet Airport Operator : PT. Angkasa Pura I (Persero) Runway Directions : 36 - 18 Runway Length : 2,650 meters Runway Width : 45 meters Surface : Asphalt concrete

1.11 Flight Recorders

The aircraft was not fitted with a Flight Data Recorder (FDR) or Cockpit Voice Recorder (CVR). Neither recorder was required by current Indonesian Civil Aviation Regulations.

1.12 Wreckage and Impact Information

The aircraft found destroy and the wreckage sent to Bitung.

1.13 Medical and Pathological Information

All aircraft occupants were fatally injured as result of impact during the accident.

1.14 Fire

There was no pre or post impact fire.

1.15 Survival Aspects

The aircraft wreckage discovered at 1650 UTC, the five victims was found at 1719 UTC. At 1800 UTC four victims and one victim was found alive and taken to nearest

7 hospital.

At 0000 UTC the survive victim declared dead. All person on board were fatally injured

At 1400 UTC dated 4 August 2011 the search and rescue operation of the PK-FUG aircraft was closed.

1.16 Tests and Research

No test and research was performed during this investigation.

1.17 Organizational and Management Information

Aircraft owner : PT. Nyaman Air Aircraft operator : PT. Nyaman Air Hanggar B6 Sepinggan International Airport Jl. Marsma R. Balikpapan, East Kalimantan 76115 Indonesia Air operator certificate : AOC/135-042

1.18 Additional Information 1.18.1 Visual flight track

The flight was a visual flight on track or route Manado-Gosowong , the investigation did not found the specified route in the standard Operation Procedure (SOP) other than the established a guidance of VFR route within Manado CTR/ TMA .

8

Figure 3: VFR route within Manado CTR /TMA

Figure 4: The aircraft PK-FUG accident route

9 1.19 Useful or Effective Investigation Techniques The investigation is being conducted in accordance with the NTSC approved policies and procedures, and in accordance with the standards and recommended practices of Annex 13 to the Chicago Convention.

10 2 ANALYSIS

To be included in Final Report.

11 3 CONCLUSIONS To be included in Final Report.

12 4 SAFETY ACTION

At the time of issuing this Preliminary Accident Investigation Report, the National Transportation Safety Committee had not been informed of any safety actions resulting from this accident.

13 5 SAFETY RECOMMENDATIONS

As a result of this accident investigation, the National Transportation Safety Committee issued recommendation to address safety issues identified in this report, as follows:

5.1 Recommendation to PT. PT Nyaman Air

The National Transportation Safety Committee recommends that PT. Nyaman Air should: • Enforce the flight operation procedure in particular VFR (Visual Flight Rules) during marginal visibility situation. • Ensure to brief the pilots to avoid entering IMC (Instrument Meteological Condition) weather condition when performing VFR flight. • Re-evaluate the single pilot operation for long distance flights particularly overwater operation. • Ensure to brief pilots with safety briefing more particular ALAR and CFIT prevention. • Produce “Pilot Guidance“ for VFR assigned route for each of operation base/ area, and have it positively controlled. And establish a local VFR procedure for each of operation area/base

5.2 Recommendation to Directorate General of Civil Aviation

The National Transportation Safety Committee recommends that Directorate General of Civil Aviation should:

• Evaluate the requirement within the CASR 135.383 regarding single pilot Helicopter operations with regard to number of passenger and overwater operation.

• Evaluate the needs of CVR/FDR installed in Helicopter having certain number of passenger.

• Reinforce the necessity for operators to conduct ALAR/CFIT briefing to all Cockpit Crew

• Reinforce the necessary for operators to produce/generate assigned VFR Route for each area of operations.

• Review the published circular/bulletin regarding pilot operations during fasting condition.

14